Health Net of California HMO 40 Plan Information
Plan Name: HMO 40
Deductibles: $1,500 per calendar year for inpatient hospital services only (prescription deductible applies)
Lifetime maximums: Unlimited
Out of Pocket Maximum: $3,000 single/ $6,000 family (Includes deductible)
Professional services:
Visit to physician: $40
Specialist consultations: $40
Prenatal and postnatal office visits: $40
Preventive Care:
Periodic health evaluations: $40
Vision screenings and exams: $40
Hearing screenings and exams: $40
Immunizations Standard: $40
Immunizations - To meet foreign travel or occupational requirements: 20%
Prostate cancer screening and exam: $40
OB/GYN exam (breast and pelvic exams, cervical cancer screening & mammography): $40
Allergy testing: $40
Allergy injection services: $40
All other injections: Covered in full
Allergy serum: Covered in full
Outpatient services:
Outpatient surgery (hospital or outpatient surgery center charges only):$250
Outpatient facility services (other than surgery): Covered in full
Hospitalization services:
Semiprivate hospital room or intensive care unit with ancillary
services (unlimited, except for non-severe mental health and
chemical dependency treatment):
$1,500 deductible applies per calendar year for inpatient
services
Surgeon or assistant surgeon services: Covered in full
Skilled nursing facility stay (limited to 100 days per calendar year): $50 per day
Maternity care in hospital or skilled nursing facility: Covered in Full after inpatient hospital services deductible is met
Hospitalization services (Continued):
Physician visit to hospital or skilled nursing facility (excluding care for chemical dependency and mental disorders): Covered in full
Emergency health coverage:
Emergency room (professional and facility charges) $100 (waived if admitted to hospital)
Urgent care center (professional and facility charges) $40
Ambulance services:
Ground ambulance: $80
Air ambulance: $80
Prescription drug coverage:
Prescription drugs filled at a participating pharmacy (up to a 30-day supply):
$100 deductible, then $15 Level I (primarily generic); $25 Level
II (primarily brand name); $50 Level III (drugs not on the
Recommended Drug List)
Prescription drugs filled through mail order (up to a 90-day supply):
$100 deductible, then $30 Level I (primarily generic); $50 Level
II (primarily brand name); $100 Level III (drugs not on the
Recommended Drug List)
Benefit Description:
Diabetic Supplies: including but not limited to pen delivery
systems, blood glucose monitoring strips, insulin needles and
syringes; lancets will be dispensed at no charge.
Diabetic Supplies
are not subject to the prescription drug deductible.
Diabetic Prescription Medications (including but not limited to
insulin and glucogon):
$25
Smoking Cessation Drugs (covered up to a 12 week course of
therapy per calendar year if you are concurrently enrolled in a
comprehensive smoking cessation behavioral support program.):
50%
Contraceptive Drugs:
$100 deductible, then $15 Level I (primarily generic); $25 Level
II (primarily brand name); $50 Level III (drugs not on the
Recommended Drug List)
Durable medical equipment: 50%
Mental health services for severe mental illness and serious
emotional disturbances of a child conditions:
Outpatient: $40
Inpatient: $1,500 deductible applies per calendar year to inpatient
services
Chemical dependency services:
Chemical dependency Treatment: Not covered
Acute care (detoxification): $100 per day (unlimited; subject to inpatient services calendar
year deductible)
Home health services (100 visits per calendar year maximum;
limited to three visits per day, two-hour maximum per visit):
$40
Other Health Net of California health insurance plans:
